What is the recommended treatment for a patient on dupilumab (dupilumab) who develops cellulitis?

Treatment of Cellulitis in Patients on Dupilumab

For patients on dupilumab who develop cellulitis, standard antibiotic therapy targeting typical skin pathogens (streptococci and staphylococci) should be initiated promptly, as dupilumab does not increase overall infection risk and may actually reduce the risk of serious infections. 1, 2

Antibiotic Selection

Mild to Moderate Cellulitis

• First-line treatment: Beta-lactam antibiotics
  • Cephalexin 500 mg four times daily
  • Dicloxacillin 500 mg four times daily
  • Amoxicillin 500 mg three times daily 1

Special Considerations

• For suspected mixed infections or periorbital cellulitis: Amoxicillin-clavulanate 875/125 mg twice daily 1
• For penicillin-allergic patients: Clindamycin 300-450 mg four times daily 1

Severe Cellulitis

• Requires hospitalization and broader coverage:
  • Vancomycin plus piperacillin-tazobactam or a carbapenem 1
  • Consider MRSA coverage only if:
    • Purulent drainage is present
    • Evidence of MRSA infection elsewhere
    • Failed initial beta-lactam therapy 1

Duration of Treatment

• 5 days of treatment is typically effective if clinical improvement occurs
• Extend treatment if infection hasn't improved within 5 days 1

Impact of Dupilumab on Infection Risk

Dupilumab actually provides some protection against infections:

• Does not increase overall infection rates compared to placebo 2, 3
• Associated with reduced risk of serious/severe infections (risk ratio 0.43) 2
• Reduces bacterial and non-herpetic skin infections (risk ratio 0.44) 2
• Reduces clinically important herpesviral infections like eczema herpeticum 2
• Long-term treatment (up to 4 years) shows no increased risk of overall systemic or cutaneous infections 3

Management Considerations

Adjunctive Measures

• Elevate the affected area to promote drainage of edema
• Address predisposing conditions (edema, obesity, venous insufficiency)
• Examine interdigital toe spaces in lower-extremity cellulitis to identify and treat fissuring or maceration 1

Monitoring

• Assess for signs of improvement within 48-72 hours
• Watch for progression of infection despite appropriate antibiotics, which may indicate:
  • Need for broader antibiotic coverage
  • Presence of abscess requiring drainage
  • Development of necrotizing infection requiring surgical intervention 1

Common Pitfalls to Avoid

• Overuse of broad-spectrum antibiotics when narrow-spectrum would suffice
• Unnecessary MRSA coverage for typical, non-purulent cellulitis
• Failure to elevate the affected area
• Inadequate duration of therapy
• Overlooking underlying conditions that can lead to recurrence 1

Dupilumab treatment should be continued during cellulitis treatment as it does not worsen infection outcomes and may actually be beneficial in reducing infection severity 2, 3.